本文選題：坐骨神經(jīng)阻滯 + 糖尿病　； 參考：《北京協(xié)和醫(yī)學(xué)院》2015年博士論文

【摘要】：前言區(qū)域麻醉常用于肢體手術(shù),其感覺和運動恢復(fù)時間是臨床上值得關(guān)注的問題,與術(shù)后鎮(zhèn)痛方案和術(shù)后功能康復(fù)有著密切的關(guān)系。隨著糖尿病患病率的逐年上升,合并糖尿病的手術(shù)病人也越來越多。糖尿病在哪些方面影響區(qū)域麻醉已成為最近的關(guān)注點,起效時間、恢復(fù)時間、神經(jīng)損傷發(fā)生率都可能受到影響。本研究擬比較糖尿病人和非糖尿病人的坐骨神經(jīng)阻滯的感覺和運動阻滯恢復(fù)時間和神經(jīng)損傷發(fā)生率,并篩選影響阻滯時間的因素。方法經(jīng)北京協(xié)和醫(yī)院倫理委員會審核并批準(zhǔn),連續(xù)納入符合入選標(biāo)準(zhǔn)和排除標(biāo)準(zhǔn)的單側(cè)下肢手術(shù)病人,按照病人是否合并糖尿病分為糖尿病組和非糖尿病組(對照組),當(dāng)進(jìn)行影響因素的篩選時則不分組。在術(shù)前用Semmes Weinstein monofilaments對坐骨神經(jīng)支配區(qū)域(足背,足底)行單絲試驗確定病人的感覺閡值,并測量空腹血糖、糖化血紅蛋白水平及糖尿病視網(wǎng)膜病變分期。所有病例均接受超聲引導(dǎo)(神經(jīng)刺激器輔助)下的臀下入路坐骨神經(jīng)阻滯,神經(jīng)周圍注射0.75%羅哌卡因20m1。在阻滯后的48小時內(nèi)每2小時隨訪一次病人(不包括阻滯后的第2夜),繼續(xù)以同樣的方法行單絲試驗檢測感覺恢復(fù)進(jìn)程,通過踝關(guān)節(jié)的活動(足背屈,足跖屈)來評估運動恢復(fù)進(jìn)程。主要研究終點是感覺和運動阻滯恢復(fù)時間。結(jié)果本研究共納入53例患者,全部完成實驗。其中糖尿病組16例,非糖尿病組37例。除年齡和ASA分級外,其他人口統(tǒng)計學(xué)指標(biāo)均無顯著統(tǒng)計學(xué)差異,術(shù)前糖尿病組的空腹血糖和HbAlc明顯高于對照組。糖尿病人接受坐骨神經(jīng)阻滯后的感覺恢復(fù)時間與非糖尿病人無差異(16小時和16小時),但運動阻滯恢復(fù)時間明顯長于非糖尿病人(21小時和16小時)。對全部病例行單因素回歸分析后發(fā)現(xiàn),運動阻滯恢復(fù)時間與血糖具有顯著相關(guān)性,而與糖化血紅蛋白的相關(guān)性不顯著。與感覺阻滯恢復(fù)時間相關(guān)的因素還有性別、術(shù)前的感覺閾值、阻滯操作時間、神經(jīng)被局麻藥包裹的比例、ALT。與運動阻滯恢復(fù)時間相關(guān)的因素還有TBil、DBi1、Cr。結(jié)論本研究發(fā)現(xiàn),在血管外科和骨科下肢手術(shù)人群中,糖尿病人接受坐骨神經(jīng)阻滯后運動阻滯恢復(fù)時間明顯延長,感覺恢復(fù)時間與非糖尿病人無差異。運動阻滯恢復(fù)時間與術(shù)前的空腹血糖具有顯著相關(guān)性,其他與阻滯恢復(fù)時間相關(guān)的因素還有性別、術(shù)前的感覺閾值、阻滯熟練程度、局麻藥擴(kuò)散范圍、以及肝腎功能,有待進(jìn)一步驗證。目的本研究擬觀察烏司他丁對充氣式止血帶下接受雙側(cè)全膝關(guān)節(jié)置換術(shù)(TKA)的病人的圍術(shù)期炎癥反應(yīng)、術(shù)后急性疼痛和慢性疼痛、以及膝關(guān)節(jié)功能康復(fù)速度的影響。方法選擇擬在大腿止血帶下接受雙側(cè)TKA的患者40例,隨機(jī)分為實驗組(U組)和對照組(C組),U組靜脈給予烏司他丁,C組給予生理鹽水。所有病人的全身麻醉方案、術(shù)后鎮(zhèn)痛方案和功能康復(fù)方案均相同。在不同時間點采樣并記錄炎癥細(xì)胞因子IL-6、TNF-α、IL-10的血漿濃度,觀察并比較病人的靜息和活動VAS疼痛評分,阿片類藥消耗量,膝關(guān)節(jié)主動屈膝角度和持續(xù)被動運動角度及步行30米所需時間。結(jié)果兩組患者的一般情況沒有顯著差異。U組的部分時間點的炎癥因子水平低于C組。U組術(shù)后4小時的靜息疼痛評分和舒芬太尼用量顯著低于C組。術(shù)后各時間點的功能康復(fù)指標(biāo)均無統(tǒng)計學(xué)差異。結(jié)論在雙側(cè)TKA術(shù)前和術(shù)中應(yīng)用烏司他丁可以減輕圍術(shù)期炎癥反應(yīng),降低術(shù)后早期的靜息疼痛評分,減少阿片類藥物用量,但對術(shù)后膝關(guān)節(jié)功能康復(fù)指標(biāo)沒有顯著影響。
[Abstract]:Preface regional anesthesia is commonly used in limb surgery. Its sensory and movement recovery time is a problem worthy of attention in clinical practice. It has a close relationship with postoperative analgesia and postoperative functional rehabilitation. With the increase of the prevalence of diabetes, more and more patients with diabetic surgery have been involved. In which areas diabetes affects regional anesthesia This study is to compare the sensory and motor block recovery time and the incidence of nerve injury in the sciatic nerve block of diabetics and non diabetic patients, and to screen the factors that affect the time of the block. Methods through the Peking Union Medical College Hospital ethics committee. The patients were reviewed and approved to be included in a single side of the lower extremities who were in accordance with the criteria for admission and exclusion. The patients were divided into diabetes group and non diabetic group (control group) according to whether the patients were combined with diabetes. They were not divided into groups when the influencing factors were screened. Semmes Weinstein monofilaments was used before the operation for the sciatic nerve area (foot back, A monofilament test was performed to determine the patient's sensory threshold and to measure fasting blood glucose, glycated hemoglobin levels and diabetic retinopathy. All cases received ultrasound guided (nerve stimulator assisted) hip approach to the sciatic nerve block, and 0.75% ropivacaine 20m1. was injected every 2 hours within 48 hours after the block. Follow up a patient (excluding second nights after block), continue to test the process of sensory recovery with the same method of monofilament test, and evaluate the process of recovery through the ankle joint activity (foot back flexion, foot metatarsal). The main end point is the sensory and motor block recovery time. The results of this study were included in 53 patients, all completed the experiment. There were 16 cases in the middle diabetes group and 37 in the non diabetic group. Except for age and ASA classification, there was no significant difference in other demographic indicators. The fasting blood glucose and HbAlc in the pre operation diabetic group were significantly higher than those in the control group. There was no difference between the sensory recovery time of the diabetic patients after the sciatic nerve block and the non diabetic patients (16 hours and 16 hours), but there was no difference between the diabetic patients and the non diabetic patients. The recovery time of the motor block was significantly longer than that of non diabetic patients (21 hours and 16 hours). After single factor regression analysis in all cases, it was found that the recovery time of motor block was significantly correlated with blood glucose, but the correlation with glycosylated hemoglobin was not significant. The factors associated with the recovery of sensory block were gender, and the preoperative sensory threshold The factors involved in the blocking operation time, the proportion of the nerve by the local anesthetic, and the factors associated with the recovery time of the ALT. and the motor block were TBil, DBi1, Cr.. Conclusion this study found that in the group of lower extremities in the vascular surgery and Department of orthopedics, the time of the motor block recovery was significantly prolonged after the sciatic nerve block of the diabetic patients, and the time of sensory recovery and non diabetic patients were significantly prolonged. No difference. There was a significant correlation between the time of motor block recovery and the preoperative fasting blood glucose. Other factors related to the recovery time were gender, preoperative sensory threshold, block proficiency, the diffusion range of local anesthetics, and liver and kidney function. The objective of this study was to observe the effect of Ulinastatin on inflatable hemostatic band. The perioperative inflammatory response, acute pain and chronic pain after operation, and the effect of knee joint function recovery were observed in patients receiving bilateral total knee arthroplasty (TKA). Methods 40 patients receiving bilateral TKA under the thigh hemostasis were selected and randomly divided into experimental group (group U) and control group (group C), group U was given Ulinastatin, and group C was given. Normal saline. All patients' general anesthesia plan, postoperative analgesia plan and functional rehabilitation program were the same. Sampling and recording the plasma concentration of inflammatory cytokines IL-6, TNF- a, IL-10 at different time points, observing and comparing the patient's resting and active VAS pain score, opioid consumption, knee joint active knee angle and continuous being Movement angle and the time required for walking 30 meters. Results there was no significant difference in the general situation between the two groups. The level of inflammatory factors at some time points in group.U was lower than that in group C.U after 4 hours of postoperative resting pain score and sufentanil dosage significantly lower than that in group C. The preoperative and intraoperative use of ulinastatin can reduce the perioperative inflammatory response, reduce the early postoperative resting pain score, reduce the dosage of opioid drugs, but have no significant effect on the postoperative rehabilitation index of the knee joint function.

【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2015
【分類號】：R614

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